BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    8120 ALARIS PCA

    MDR report key: 11099587 · Received December 31, 2020

    Report

    Report Number
    2016493-2020-82880
    Event Type
    Malfunction
    Date Received
    December 31, 2020
    Report Date
    May 22, 2019
    Manufacturer
    CAREFUSION SD
    Product Code
    MEA
    UDI-DI
    10885403812002
    PMA / PMN Number
    K043299
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 1

    THIS REPORTED EVENT AND SUBSEQUENT REPAIRS WERE INVESTIGATED THROUGH THE SERVICE REPAIR PROCESS. FAILURE DATA AND PARTS-USED INFORMATION WERE REVIEWED FOR THE SAP AND TRACK WISE FILES AND FOUND RELEVANT TO THE SERVICE REPAIR. A REVIEW OF THE SOURCE DEVICE SERVICE HISTORY RECORD WAS PERFORMED FROM THE DATE OF MANUFACTURE TO THE DATE CORRESPONDING TO THIS SERVICE NOTIFICATION NUMBER. THE DATABASE SHOWED NO QUALITY NOTIFICATIONS WERE OPENED FOR THE DEVICE. A REVIEW OF THE DEVICE HISTORY RECORD IN SAP FOR SN (B)(4) WAS PERFORMED FROM THE DATE OF THE MANUFACTURE TO DATE OF THE RELEASE OF PRODUCT, WHICH CONFIRMED THAT THIS DEVICE WAS NOT INVOLVED IN A PRODUCTION FAILURE, AND PRODUCT WAS RETURNED FOR SERVICING WHICH CORRELATES TO THE CUSTOMER REPORTED ISSUE. A TRACKWISE COMPLAINT HISTORY REVIEW WAS COMPLETED, AND IT WAS CONFIRMED THAT THERE WERE ADDITIONAL COMPLAINTS RECEIVED WITH SIMILAR SN (B)(4) FOR THE SAME OR RELATED FAILURE MODE. THE CUSTOMER STATED THAT THERE WAS NO PATIENT INVOLVEMENT.

    Description of Event or Problem · 1

    05/22/2019 11:08:54 RFC_REPAIRS (RFC_REPAIRS) PO FOR $529. PLEASE EMAIL ESTIMATE AND WHO TO CALL WITH CREDIT CARD AUTHORIZATION. 05/28/2019 10:59:18 MARITES MALIG (MMALIG) PHONE 858-458-7000 7000 DEVICE WAITING FOR CCRD INFO FRONT COVER(CRACKED UP LT CNR) REAR CASE(CRACKED BTM LT) BARREL CLAMP (CRACKED HOLDER) FRONT DOOR(CRACKED ) REAR DOOR (CRACKED BOTTOM MOUNT) RETAINER(CRACKED ) 06/07/2019 06:38:20 LAURYNE WASAN (LWASAN) UPDATED FROM MNR TO MJR FOR THE MAJOR REPAIRS NEEDED PER MARITES MALIG, SERVICE TECH. REPAIR APPROVED BY RYKIE PRATT, BIOMED, AT [email protected] FOR $529. USE NEW PO# 819-1040. PER RYKIE, PLEASE BILL REPAIR TO PO - NO CCRD NEEDED. 06/19/2019 12:59:06 ANNETTE A MENDEZ (AMENDEZ) 1001901752870009203700102839890707

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1567302 8120 ALARIS PCA PUMP,INFUSION MEA CAREFUSION SD 8120 10885403812002

    Patients

    Seq Age Sex Outcome Treatment
    1